New Hampshire Condominium Quote Request

Brownell Insurance Center, Inc - Derry NH - Your NH Auto and Homeowners Specialists

New Hampshire Condominum Insurance Quote

Please complete the following form and one of our agents will contact you promptly to discuss coverages and pricing for your particular needs.

*This form is for information only and does not afford any coverage. Coverage must be submitted or bound by one of our authorized insurance agents and initial premium paid before any insurance is in force.

Personal Information

First Name:
Last Name:
Address:
City:
State:	Zipcode:
Home Phone:
Work Phone:
Cell Phone:
Where to Contact:	When to Contact: AM PM
Email Address:
*Please note: Without a valid email address, we will be unable to return your E-Quote!
Social Security Number:	(Optional)
Date of Birth:	mm/dd/yyyy
**What date would you like coverage to begin?	mm/dd/yyyy
**Please note: Select a date that is at least three days from current date.
General Insurance Information
Is this your primary residence?	Yes No
Last Name:
Who is your current Insurance Carrier?
Do you currently have auto insurance?	Yes No (If so, this could qualify you for an additional credit.)
Number of property insurance claims in the last 5 years?
Is any business or child care conducted on your property?	Yes No
If yes, please describe what type:
Do you own pets?	Yes No If yes, what kind?
Do you have a pet that has bitten anyone?	Yes No
Information About Your Home's Location
County:
Name of Responding fire department:
Distance to fire department:	(miles, ie. 0.5, 1.0)
Distance to fire hydrant:	feet
Is your home subject to flood?	Yes No
Information About Your Home's Construction
Construction type:
How many condomiums in your building?:
Do you have any of the following:	Smoke Detectors Fire Extinguishers Dead Bolt Locks Fire Alarm Alerts Central Station Fire Alarm Alerts Police Station Burglary Alarm Alerts Central Station Burglary Alarm Alerts Police Station
What is Your Primary Source for Heating Your Home?	If Other Explain:
Do you have a wood, coal or pellet stove?	Yes No
Was the device inspected by the local Fire Department or Building Inspector?	Yes No
Is the device/installation UL Listed and installed by a qualified contractor?	Yes No
Are the chimney and flue pipe cleaned annually?	Yes No
Number of Units between fire walls?
What floor is your apartment or condominium on?
Information About Your Coverage
How much coverage do you want on your household belongings/personal property? ($15,000 min. limit, $5,000 per room)
Please select a personal liability coverage amount:
Please select a medical payments coverage amount:
Please select the deductible amount:
Would you like increased coverage for Credit Cards, Fund Transfer Cards, Forgery and Counterfeit Money Coverage? Yes No
Would you like to include Identity Fraud Expense Coverage? Add to your renters policy for $25.00 per year. Yes No
Would you like to include Valuable Items coverage? Yes No
Information About Your Valuable Items
Please enter the corresponding numeric dollar values next to the items you are interested in insuring: Camera China & Crystal Fine Arts Firearms Furs Jewelry Musical Instruments Personal Computers Silverware
Thank you for your information. We will email you back in 2 business days. If you have any questions we will call you directly so we can give you the most accurate quote possible. If you have any questions or concerns, please call us at 603-437-1992.

Brownell Insurance Center, Inc. • 122 West Broadway, Derry, NH 03038
Phone: 603.437.1992 • Fax: 603.437.4846 • www.BrownellInsurance.com